Provider Demographics
NPI:1255300380
Name:SHAUGHNESSY, MICHAEL WALTER (MA)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:WALTER
Last Name:SHAUGHNESSY
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5616 LYNN LAKE DR S
Mailing Address - Street 2:APT. A
Mailing Address - City:SAINT PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33712-6224
Mailing Address - Country:US
Mailing Address - Phone:941-544-2175
Mailing Address - Fax:
Practice Address - Street 1:7511 LITTLE RD
Practice Address - Street 2:SUITE 101
Practice Address - City:NEW PORT RICHEY
Practice Address - State:FL
Practice Address - Zip Code:34654-5531
Practice Address - Country:US
Practice Address - Phone:941-544-2175
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-14
Last Update Date:2014-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH9936101YM0800X
101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL12349095OtherCAQH PROVIDER ID